Efficacy and safety of nephron‐sparing surgery

To analyse the current evidence of efficacy and safety of nephron‐sparing surgery (NSS) that encompasses open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN) and robotic partial nephrectomy in the management of localized renal cell carcinoma (RCC). Oncological data, complications and postoperative renal function were reviewed for the most important series of partial nephrectomy. Partial nephrectomy (PN) provides similar oncological control as radical nephrectomy (RN) and is superior to RN with respect to preserving renal function and preventing chronic kidney disease. OPN remains the first treatment option for T1 renal tumors in centers without advanced laparoscopic expertise. Indications for LPN have expanded as such that LPN is suited for most renal tumors provided that the procedure is carried out in selected patients by an experienced laparoscopic surgeon. Warm ischemia time should be kept within 20 min, which is currently recommended regardless of surgical approach. In experienced hands, LPN yields intermediate oncological efficacy and renal function outcome comparable to open surgery in the treatment of pT1 renal tumors. Positive surgical margin rates are comparable after LPN and OPN. In contemporary series, the morbidity of LPN is decreasing to become similar to that of OPN. Preliminary results with robotic PN are comparable to results obtained with LPN. Additional studies are required to validate these results and compare with other current methods, such as thermal ablation. NSS is effective and safe for the management of localized RCC and is the gold standard to which new ablative techniques need to be compared.     

Nephrometry score matched robotic vs. laparoscopic vs. open partial nephrectomy

To compare perioperative outcomes in the three most common partial nephrectomy modalities: robotic (RPN), laparoscopic (LPN), and open (OPN), matched for nephrometry scores. Patients aged 16–85 who underwent RPN, LPN, or OPN from 2007 to 2014 for localized renal carcinoma within our healthcare system were enrolled. Age, sex, body mass index, and Charlson Comorbidity Index (CCI) as well as perioperative outcomes of estimated blood loss (EBL), length of hospital stay (LOS), ischemia time (IT), change in eGFR, positive margin rate, operative time (OT), and emergency room visit rates were compared between RPN, LPN, and OPN using the R.E.N.A.L nephrometry score. A total of 862 patients underwent partial nephrectomy (523 LPN, 176 OPN, and 163 RPN). Patients who underwent OPN were significantly older, and had higher nephrometry scores and CCI. When matched for nephrometry scores, minimally invasive (LPN and RPN) compared to OPN had lower EBL (<?0.0001), shorter LOS (<?0.0001), shorter IT (<?0.001), and less change in eGFR (<?0.001), particularly in nephrometry scores higher than 8 (0.0099). Comparing RPN with LPN, RPN had significantly shorter OT in all nephrometry scores (<?0.001); shorter IT and LOS in nephrometry scores higher than 7. Our study suggests that minimally invasive partial nephrectomy may have superior outcomes to OPN when matched by nephrometry scores, particularly at higher scores and for RPN. This finding may contribute to a surgeon’s decision in the approach to partial nephrectomy.     

后腹腔镜与开放手术行肾部分切除术治疗肾肿瘤的临床效果比较

目的：通过与开放性肾部分切除术（OPN）的临床效果比较,评价后腹腔镜肾部分切除术（LPN）的临床价值。方法：回顾性分析后腹腔镜肾部分切除术（38例,LPN手术组）和同期施行开放性肾部分切除术（46例,OPN手术组）的临床资料,就两组患者一般资料、手术时间、患肾热缺血时间、术中出血量、术后肠道功能恢复时间、术后止痛药用量、术后住院天数、术后血清肌酐升高幅度及术后并发症等指标进行比较。根据数据类型选用x2检验、两样本t检验或Wilcoxon秩和检验,以P〈0．05为差异有统计学意义。结果：两组患者的一般资料差异无统计学意义（P〉0．05）,具有可比性。LPN手术组在术中出血量、术后肠道功能恢复时间、术后止痛药用量、术后住院天数方面及术后并发症发生率均优于DPN手术组（P〈0．05）,但前者的患肾热缺血时间明显长于后者（P〈0．05）。LPN手术组和OPN手术组的手术时间及术后血清肌酐升高幅度差异无统计学意义（P〉0．05）。两组患者送检标本的手术切缘均为阴性,随访18个月均无一例复发。结论：后腹腔镜肾部分切除术治疗肾肿瘤疗效肯定,与传统的开放性肾部分切除术相比,具有创伤小、恢复快、疗效与开放性手术相当等优点,是目前治疗肾肿瘤较理想的手术方法,值得进一步推广。     

Laparoscopic and open partial nephrectomy: cost comparison with analysis of individual parameters

INTRODUCTION: Laparoscopic partial nephrectomy (LPN) is less morbid than open partial nephrectomy (OPN), but the high cost of new technologies used in LPN may make this a significantly more expensive procedure. In this study, the overall costs of OPN and LPN were compared using data extracted from the literature, and a series of sensitivity analyses were performed to determine the impact of individual cost components on overall cost. MATERIALS AND METHODS: Data on operating room (OR) time, equipment use, and length of stay (LOS) were abstracted after a comprehensive literature review of LPN and OPN. Decision tree models were devised to estimate the cost of each treatment using the DATA program (TreeAge software 3.5). LPN model assumptions included one that used all reusable equipment, all disposable equipment, and a hand-assist model. One and two-way sensitivity analyses were performed to evaluate the effect of individual treatment variables on overall cost. RESULTS: The literature yielded 12 OPN and 13 LPN articles, comprising a total of 574 and 949 patients, respectively. The weighted mean LOS were 5.7 and 2.9 days (<0.001); average tumor sizes were 3.2 cm and 2.5 cm (P = 0.016); and the weighted mean OR times were 184 and 187 minutes for OPN and LPN (P = 0.7), respectively. The LPN model using all disposable equipment is less costly than OPN by $431 ($8450 v $8019). The slight cost superiority of the laparoscopic approach was driven by shorter LOS. One-way sensitivity analyses showed that LPN is less costly if the OR time of LPN is less than 146 minutes; LOS after LPN is less than 4.6 days; or LPN OR supply costs are less than $1670. Two-way sensitivity analyses demonstrated the effects of modifying OR time, LOS, and surgical equipment on the cost-equivalence of LPN and OPN. CONCLUSIONS: Laparoscopic partial nephrectomy can be cost equivalent to the open approach in managing small renal masses if the OR time, LOS, and equipment costs are closely monitored. The high cost of new technologies can be offset by shorter LOS and decrease in OR time.     

A cost comparison of nephron-sparing surgical techniques for renal tumour

OBJECTIVE: To compare costs associated with open partial nephrectomy (OPN), laparoscopic PN (LPN) and percutaneous radiofrequency ablation (PRF) in consecutive patients undergoing nephron-sparing surgery. PATIENTS AND METHODS: The charts and costs were reviewed for all 46 patients undergoing nephron-sparing PN at our institution from March 2003 to March 2004. Clinical characteristics, operative techniques, radiographic and pathological information were recorded. Detailed cost information for room and board, laboratory, pharmacy, radiology, operating room, surgical supplies, anaesthesia, recovery room, electrocardiography and respiratory services were obtained from our institution. RESULTS: The hospital stay was significantly shorter for PRF (0.5 days) than either LPN (1.86) and OPN (4.94). PRF was statistically less costly than LPN and OPN, with mean (sd) costs of (US dollars) 4454 (938), 7013 (934) and 7767 (1605). There was no significant difference in cost between LPN and OPN. Surgical supply costs were significantly higher for LPN and PRF than OPN. LPN had less than a third of the room and board costs of OPN (P < 0.001). Decreases in room and board were also associated with lower pharmacy and laboratory costs. CONCLUSIONS: PRF is significantly less costly than LPN and OPN; LPN is cost-equivalent to OPN as the shorter stay compensates for significantly higher surgical supply costs. In those patients with tumours of appropriate size and location, minimally invasive approaches can decrease the morbidity, with cost benefits.     

Impact of collecting-system repair during laparoscopic partial nephrectomy

PURPOSE: Laparoscopic partial nephrectomy (LPN) is a complex procedure frequently reserved for small, peripherally located renal tumors. Deep, infiltrating lesions often necessitate collecting system repair (CSR), mandating further intracorporeal suturing and reconstruction. We compared our experience with LPN where CSR was and was not required after tumor resection. PATIENTS AND METHODS: Between October 2002 and December 2005, 84 patients underwent LPN. Tumor excision with pelvicaliceal system injury occurred in 52 patients, whereas 32 patients required no CSR. Perioperative and pathologic data were compared in the two groups. RESULTS: Tumors with CSR were larger (mean 2.9 cm v 2.1 cm for non-CSR procedures; P = 0.001) and had larger pathologic specimen weights (mean 58.2 g v 21.8 g; P = 0.05). Blood loss (mean 210 mL) and hospital stay (mean 2.7 days) were similar in the two groups. Warm ischemia time (WIT) (mean 36.6 v 27.7 minutes; P < 0.001) and operative time (mean 238 v 207 minutes; P = 0.03) were longer in the CSR group. The intraoperative hemorrhage rate (7.7% v 9.4%; P = 0.34) and rate of conversion to open surgery (7.7% v 9.4%; P = 0.29) were similar, as were the incidences of postoperative bleeding (7.7% v 3.1%; P = 0.28) and urinary leakage (1.9% v 0; P = 0.62). CONCLUSION: Laparoscopic partial nephrectomy involving CSR is a technically demanding procedure that necessitates longer WIT and overall surgical time. However, when performed by an experienced laparoscopic surgeon, comparable complication rates and blood loss are observed. Technical variations for hemostasis, such as argon-beam coagulation and FloSeal and the use of the LapraTy clip for pelvicaliceal and parenchymal suture repair may facilitate LPN for more deeply invasive tumors.     

Laparoscopic vs open partial nephrectomy in consecutive patients: the Cornell experience

OBJECTIVE: To compare a contemporary series of laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) at one institution, to evaluate the size and types of tumour in each group and the early outcome after each procedure, as LPN is replacing open radical nephrectomy as the standard of care for uncomplicated renal tumours but partial nephrectomy remains significantly more difficult laparoscopically, especially if the goal is to duplicate the open surgical technique. PATIENTS AND METHODS: We retrospectively analysed the records of all patients who underwent partial nephrectomy at our institution from January 2000 to April 2004, identifying 66 who had LPN and compared them with 59 who had OPN (mean age at LPN and OPN, 62.1 and 64.2 years, respectively; 70% men in each group). Variables analysed included operative time, blood loss, creatinine levels before and after partial nephrectomy, time to resuming clear liquids and regular diet, length of stay, tumour size, tumour pathological type and complications. Groups were compared using Student's t-test, with P < 0.05 taken to indicate significance. RESULTS: Of those having LPN, 59% had right-sided tumours, vs 53% in the OPN group; the respective mean tumour size was 2.2 and 3.4 cm, the mean operative duration 144 and 239 min (both P < 0.001), and the mean estimated blood loss 236 and 363 mL (P = 0.09). Seven patients in the OPN group had obligatory partial nephrectomy for either a solitary kidney (two) or azotaemia (five). No patient in the LPN group required an obligatory partial nephrectomy. Serum creatinine levels were measured before and 1 and 2 days after surgery, and were 88, 88 and 97 micromol/L for the LPN group, and 97, 106 and 106 micromol/L for the OPN group. Clear fluids were started a mean of 41 h after surgery, a regular diet resumed 76 h after and discharge was 129 h after surgery in the OPN group; the respective values for the LPN group were 24 h (P = 0.01), 49 h (P = 0.2) and 82 h (P < 0.001). Complications were similar in both groups but the pathological subtypes differed. CONCLUSIONS: LPN offers early functional advantages over OPN in terms of earlier resumption of diet and slightly earlier discharge. However, the two groups of patients were clearly not evenly matched for size nor pathological subtypes, with larger, malignant subtypes more predominant in the OPN group. These results suggest that while LPN is a safe, effective treatment for small renal tumours, obligatory partial nephrectomy or large tumours continue to be performed using open techniques with good results.     

机器人辅助和普通腹腔镜肾部分切除术治疗肾血管平滑肌脂肪瘤的比较

目的对比肾血管平滑肌脂肪瘤（RAML）患者中应用机器人辅助肾部分切除术（RAPN）与普通腹腔镜下肾部分切除术（LPN）的安全性及有效性。 方法收集2016年1月至2021年8月我院收治的肾血管平滑肌脂肪瘤患者198例,其中80例为机器人辅助肾部分切除术组,118例为腹腔镜下肾部分切除术组。采用倾向性评分匹配后分析比较两术式的临床指标。 结果198例患者中有3例术中中转开放（包括2例LPN,1例RAPN）,1例LPN术中损伤输尿管,其余均顺利完成手术。RAPN组术中热缺血时间显著低于LPN组;RAPN组术后血红蛋白（Hb）差值百分比及eGFR差值百分比均显著低于LPN组（P<0.05）;手术时间、术中估计出血量、术中及术后输血率、术后并发症、术后引流量、引流管留置时间、胃肠道功能恢复时间、术后住院时间方面两组差异无统计学意义。 结论在肾血管平滑肌脂肪瘤患者中,应用机器人辅助肾部分切除术相较于普通腹腔镜下肾部分切除术具有显著优势,手术出血更少,热缺血时间更短,能更大程度保留肾功能。     

Comparison of the Loss of Renal Function after Cold Ischemia Open Partial Nephrectomy,Warm Ischemia Laparoscopic Partial Nephrectomy and Laparoscopic Partial Nephrectomy Using Microwave Coagulation

Purpose

Nephron sparing surgery is an effective surgical option in patients with renal cell carcinoma. Laparoscopic partial nephrectomy involves clamping and unclamping techniques of the renal vasculature. This study compared the postoperative renal function of partial nephrectomy using an estimation of the glomerular filtration rate (eGFR) for a Japanese population in 3 procedures; open partial nephrectomy in cold ischemia (OPN), laparoscopic partial nephrectomy in warm ischemia (LPN), and microwave coagulation using laparoscopic partial nephrectomy without ischemia (MLPN).

Materials and Methods

A total of 57 patients underwent partial nephrectomy in Yokohama City University Hospital from July 2002 to July 2008. 18 of these patients underwent OPN, 17 patients received MLPN, and 22 patients had LPN. The renal function evaluation included eGFR, as recommended by The Japanese Society of Nephrology.

Results

There was no significant difference between the 3 groups in the reduction of eGFR. eGFR loss in the OPN group was significantly higher in patients that experienced over 20 minutes of ischemia time. eGFR loss in LPN group was significantly higher in patients that experienced over 30 minutes of ischemia time.

Conclusion

This study showed that all 3 procedures for small renal tumor resection were safe and effective for preserving postoperative renal function.Key Words: eGFR, Partial nephrectomy, Renal function, Laparoscopic partial nephrectomy     

腹腔镜肾部分切除术治疗肾门旁肾肿瘤(附14例报告)

目的:探讨及总结腹腔镜肾部分切除术治疗肾门旁肾肿瘤的疗效及经验.方法:2006年1月至2011年5月经腹腔镜肾部分切除术治疗14例肾门旁肾肿瘤,肿瘤直径平均2.4 cm.观察手术时间、热缺血时间、术中出血量、术中术后并发症、切缘阳性率等.结果:14例手术均顺利完成.热缺血时间平均27.6 min,术中出血量平均105 ...     

腹腔镜与开放性肾部分切除术治疗小肾癌的安全性与疗效分析

目的 比较腹腔镜与开放性肾部分切除术治疗小肾癌的安全性与近期治疗效果.方法 2004年1月至2009年3月T1aN0M0的肾癌患者110例,均接受肾部分切除术,其中腹腔镜肾部分切除术(LPN)52例(LPN组),开放性肾部分切除术(OPN)58例(OPN组).评估患者的手术时间、肾动脉阻断时间、手术并发症、术后恢复和手术切缘情况.结果 LPN组和OPN组的平均手术时间分别为177.8和126.7 min(P<0.01),肾动脉阻断时间分别为28.3和21.9 min(P>0.05);两组各有2例(3.8%)和1例(1.7%)需要输血(P>0.05);手术前后肌苷变化两组差异无统计学意义(P>0.05);两组分别有6例(11.5%)和8例(13.8%)需缝合集合系统(P>0.05);分别有6例(11.5%)和8例(13.8%)术后出现血尿(P>0.05);未出现尿瘘或其他严重的并发症.患者的手术切缘均为阴性.两组患者平均术后住院天数差异有统计学意义(P<0.01).结论 LPN的安全性和治疗效果与OPN相同,但术后恢复快于OPN.对于经选择的患者和有丰富经验的医师,可以考虑将LPN作为治疗T1aN0M0肾癌的首选术式.     

Hand-assisted and conventional laparoscopic live donor nephrectomy: a comparison of two contemporary techniques

BACKGROUND AND PURPOSE: Laparoscopic nephrectomy may make kidney donation more attractive. Modifications such as hand assistance may improve surgical outcomes. We compared our initial experience with hand-assisted laparoscopic nephrectomy with that of the conventional laparoscopic technique. PATIENTS AND METHODS: Two series of similar patients underwent conventional laparoscopic donor nephrectomy (LDN; N = 15) or hand-assisted laparoscopic donor nephrectomy (HLDN; N = 29). Operative time, warm ischemia time, estimated blood loss, complications, analgesic use, postoperative recovery, and serum creatinine concentration were compared. RESULTS: Open conversion was required in one HLDN patient because of intra-abdominal adhesions, and this patient was excluded from further analysis. The operative time, time to kidney extraction, and warm ischemia time were significantly shorter in the HLDN group, averaging 204.8 v 275.7 minutes, 173.4 v 239.3 minutes, and 2 minutes 21 seconds v 3 minutes 45 seconds, respectively. The intraoperative complication rates were 3.6% and 13.3%, respectively (P = 0.07). The postoperative complication rates were 6.8% and 6.7%. All grafts were functioning at the end of the study period, and there were no differences in rejection episodes, need for dialysis, complications, or nadir creatinine concentration according to the method of harvest. CONCLUSIONS: Hand-assisted laparoscopic donor nephrectomy provides shorter operative and warm ischemia times without a significant increase in donor morbidity.     

Margin and complication rates in clampless partial nephrectomy: a comparison of open,laparoscopic and robotic surgeries

In performing partial nephrectomy (PN), surgeons focus on complete removal of tumor, preservation of renal function, the absence of major perioperative complications, expressed by the formula margin, ischemia and complication (MIC). The aim of current study was to perform a single-institution comparison of clampless open (OPN), laparoscopic (LPN) or robot-assisted (RAPN) PN as well as to evaluate pre-, intra- and postoperative factors that may influence achievement of ideal MIC. All consecutive clampless OPN, LPN or RAPN performed by experienced surgeons between 2006 and 2015 were included in the analysis. MIC was defined as negative surgical margin plus zero-ischemia plus absence of any grade ≥3 complications according to Clavien–Dindo classification. Bivariate and multivariate logistic regression models were fitted to predict the MIC. Odds ratios with 95 % confidence intervals were calculated. 80 patients underwent OPN, 66 LPN and 31 RAPN, and both groups had similar characteristics. The MIC rate was 67.5, 86.3 and 83.3 % in the OPN, LPN and RAPN groups, respectively (p = 0.016). At logistic regression analysis, surgical approach (p = 0.03) and operative time (p = 0.008) were independent predictors of the MIC rate. When stratified according to the surgical approach, preoperative aspects and dimensions used for an anatomical classification (PADUA) score, LPN, RAPN and operative time were independent predictors of MIC rate (p = 0.0488, p = 0.0494, p = 0.0479 and p = 0.0108, respectively). Clampless LPN and RAPN have an efficacy and safety profile that is on par with OPN, offering the additional benefits of a reduced operative time, blood loss, on demand ischemia and rate of high-grade complications.     

Current Status of Robot-Assisted Partial Nephrectomy

The incidence of incidentally diagnosed small renal masses is rising. Although open partial nephrectomy (OPN) remains the reference standard for clinically localized renal lesions, growing experience with minimally invasive PN has demonstrated equivalent oncologic efficacy and improved short-term perioperative outcomes compared to open techniques. Compared to the technically demanding laparoscopic PN (LPN), robotic PN (RPN) overcomes a number of the technical hurdles of LPN with a shorter learning curve, and now has emerged as an attractive minimally invasive treatment option for amenable tumors. Although experience with RPN has been limited to date, early series have demonstrated short-term oncologic outcomes comparable to OPN and equivalent perioperative outcomes to LPN (all ≤ level III evidence). Although prospective evidence would be ideal, clinical trial comparisons with LPN and OPN will be fraught with accrual challenges and are not expected in the near future. This review summarizes the advantages and indications for a robotic approach, operative principles and emerging technologies, early functional and oncologic outcomes, and expected future advances of RPN for localized renal tumors.     

腹腔镜肾部分切除术（附160例报告）

目的：介绍我院行腹腔镜肾部分切除术（LPN）的体会。方法：2004年1月～2009年11月采用腹腔镜经腹腔或后腹腔途径对160例肾肿瘤患者行LPN。局限性肾透明细胞癌135例,乳头状肾细胞癌6例,嫌色细胞癌2例,嗜酸细胞腺瘤2例,肾血管平滑肌脂肪瘤15例,肿瘤直径4．1cm（2．0～6．0cm）。左侧86例,右侧74例。观察手术时间、术中出血量、住院大数、并发症及手术效果。结果：160例手术均顺利完成。平均手术时间70min（40～150min）,152例患者平均血管阻断时间26min（20～55min）,8例患者未阻断肾血管。术中平均出血量75ml（10～300m1）。4例术后出现迟发出血,予以保守治疗。2例术后出现漏尿。平均住院时间7．5天（6～15天）。随访2～70个月肿瘤无复发。结论：LPN安全、有效,对肿瘤压迫集合系统的,腔镜下缝合也是安全有效的,随着手术技术的熟练,对复杂肾肿瘤行LPN,肾脏功能保留和肿瘤控制效果逐渐提高。     

Outcome of laser-assisted laparoscopic partial nephrectomy without ischaemia for peripheral renal tumours

Objectives

Evaluation of clamp-off laser-assisted laparoscopic partial nephrectomy technique (LLPN) compared to the clamp-off laparoscopic (LPN) and open (OPN) techniques.

Patients and methods

Between September 2008 and July 2011, 36 patients suffering from small peripheral renal tumours (RT) underwent LLPN (n?=?12), LPN (n?=?12) and OPN (n?=?12) in a prospective single-centre study. RT were excised with laser, Sonosurg or monopolar scissors during LLPN, LPN and OPN, respectively. Blood vessels are identified and sutured before opening them; alternatively, laser energy was used to coagulate them (LLPN). Early and late postoperative complications were assessed. Follow-up was done according to EAU-guidelines.

Results

Mean age was 64.9?years. Mean operative time was 135.8?min (100–180) versus 144.2 (85–255) versus 113.6 (50–170) for LLPN versus LPN versus OPN, respectively. Median estimated blood loss (EBL) was 170.8?ml (50–600) versus 245.2 (50–700) versus 425.8 (100–900) for LLPN versus LPN versus OPN, respectively. Tumours (19 right and 17 left) were located in upper (11), midparenchyma (13) and lower pole (12). Mean tumour size was 2.7?cm (1.2–5.5). There were no reported perioperative complications/conversions. There were no positive margins. Histological evaluations were not compromised in any LLPN-case. Compared to LPN, LLPN offered significant lower EBL, shorter operative time, otherwise, comparable results. Follow-up was uneventful without tumour recurrences.

Conclusion

Current prospective comparative study shows that LLPN is a reproducible efficient alternative to LPN/OPN. Besides the absence of renal ischaemia, LLPN offered lower EBL, good haemostasis and minimal parenchyma damage. Surgical and oncological outcomes are comparable to LPN and OPN.     

Laparoscopic partial nephrectomy: an update on contemporary issues

Laparoscopic partial nephrectomy (LPN) is a technically challenging procedure with up to 5-year follow-up data. In this article, incidence of renal cell carcinoma, indications, and contraindications for LPN are presented. In addition, LPN for benign diseases such as atrophic renal segments associated with duplicated collecting systems and calyceal diverticula associated with recurrent UTIs are presented. Hilar clamping, ischemic time, positive margins, and port-site metastasis, in addition to complications and survival outcomes, are discussed. The advantages of lower cost, decreased postoperative pain, and early recovery have to be balanced with prolonged warm ischemia. Its long-term outcomes in terms of renal insufficiency or hemodialysis requirements have not been defined completely. Randomized clinical trials comparing open partial nephrectomy (OPN) versus LPN are needed.     

Comparing the outcomes of open,laparoscopic and robot-assisted partial nephrectomy: a network meta-analysis

Objective

To perform a systematic review and network meta-analysis (NMA) to determine the advantages and disadvantages of open (OPN), laparoscopic (LPN), and robot-assisted partial nephrectomy (RAPN) with particular attention to intraoperative, immediate postoperative, as well as longer-term functional and oncological outcomes.

Methods

A systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-NMA guidelines. Binary data were compared using odds ratios (ORs). Mean differences (MDs) were used for continuous variables. ORs and MDs were extracted from the articles to compare the efficacy of the various surgical approaches. Statistical validity is guaranteed when the 95% credible interval does not include 1.

Results

In total, there were 31 studies included in the NMA with a combined 7869 patients. Of these, 33.7% (2651/7869) underwent OPN, 20.8% (1636/7869) LPN, and 45.5% (3582/7689) RAPN. There was no difference for either LPN or RAPN as compared to OPN in ischaemia time, intraoperative complications, positive surgical margins, operative time or trifecta rate. The estimated blood loss (EBL), postoperative complications and length of stay were all significantly reduced in RAPN when compared with OPN. The outcomes of RAPN and LPN were largely similar except the significantly reduced EBL in RAPN.

Conclusion

This systematic review and NMA suggests that RAPN is the preferable operative approach for patients undergoing surgery for lower-staged RCC.     

后腹腔镜肾部分切除术治疗局限性肾肿瘤的临床价值

目的:对比分析后腹腔镜肾部分切除术(RLPN)与开放肾部分切除术(OPN)治疗局限肾肿瘤的临床疗效。方法:43例肾肿瘤患者随机分为两组:其中19例行RLPN,24例行OPN。观察手术时间、术中肾热缺血时间、术中出血量、术后引流量、术后胃肠功能恢复时间、术后住院时间。结果:RLPN组患者的手术时间及术中肾缺血时间均明显较OPN组长,而术中出血量则明显少于OPN组,且胃肠恢复时间及住院时间均明显较OPN组少,差异有统计学意义(P0.05)。结论:后腹腔镜下肾部分切除术治疗局限肾肿瘤疗效确切,出血量及并发症少,微创优势明显,是替代开放手术治疗局限肾肿瘤的有效方法。     

Multiple factor analysis of urine leaks after retroperitoneal laparoscopic partial nephrectomy

Laparoscopic partial nephrectomy (LPN) is increasingly becoming a definitive therapeutic option for the treatment of small (less than 4 cm) and select moderate-sized (less than 7 cm) renal tumors. Postoperative hemorrhage and urine leak are the most pertinent complications after nephron-sparing surgery, open or laparoscopic. To our knowledge, the risk factors of urine leaks after retroperitoneal LPN have not been studied. We retrospectively analyzed our experience with retroperitoneal LPN to determine risk factors for postoperative urine leak complications. The records of 236 patients who underwent retroperitoneal LPN for renal tumor from March 2003 to October 2010 were reviewed retrospectively. Urine leak was strictly defined as continued urine output from the drain after postoperative day 2. In our series, 39 patients (16.5%) had urine leak complications. On multivariate analysis, mean estimated blood loss (p = 0.0120) and computed tomography angiogram (CTA) examination (p = 0.0286) were independent predictive factors of urine leaks. Moreover, the intraoperative blood loss was significantly reduced in patients undergoing CTA examination (p = 0.0375). Our investigation showed that factors such as intraoperative blood loss and CTA examination are predictors of urine leaks after retroperitoneal LPN. Less intraoperative blood loss to obtain a clear operative field and meticulous suturing technique are necessary to reduce urine leak probability.